Repackaging mental health programs in low- and middle-income countries

Abstract

Byline: K. Jacob World Organization (WHO) recognized the need to bridge the gap between the enormous burden of mental illness and available services for their management. WHO mental health Global Action Programme (mhGAP) was endorsed by the 55 [sup]th World Assembly in 2002 and launched in 2008. [sup][1],[2] program highlights the morbidity, mortality and global burden of disease of people with mental, neurological and substance use disorders. It recognizes that the treatment gap is as much as 75% in many low- and middle-income countries (LMICs). four core strategies identified by the program are information, policy and service development, advocacy, and research. program supports advocacy initiatives and provides normative guidance in improving health systems to deliver care for these disorders. It is specifically aimed at LMICs and advocates partnerships to reinforce and accelerate efforts and increase investments toward providing services. It provides health planners, policymakers, and donors with a set of clear and coherent activities and programs. However, careful readings of these initiatives lead to a deja vu experience for the more discerning. It suggests that the mhGAP is the latest in a series of repackaged solutions to bridge the huge gap between the burden of mental illness and mental health care delivery. This article briefly summarizes similar past initiatives and their failures. It also highlights the major barriers to the delivery of mental health services in many It argues that the reality in LMICs has to be factored into mental health care delivery for success. Past Initiatives and Failures WHO spearheaded the crusade to incorporate the mental health component into primary health care in LMICs in the 1970s. [sup][3] The WHO expert committee reports, their multinational collaborative community care projects in mental health and the Alma Ata Declaration of Health for all by 2000 formed the platform to launch national mental health programmes in LMICs. Many LMICs set up model programs which were evaluated and found to be successful. These demonstration projects subsequently formed the basis of national implementation strategies. [sup][4],[5],[6] programs aimed to establish nodal training centers, train local health professionals for early detection and management, and provide outpatient clinical services and facilities for inpatient treatment. They aimed to reduce stigma through mass education and provide data for future planning. Nevertheless, the success of the model projects did not result in mental health care being implemented on a national scale in many [sup][7] vast majority of the population are outside these programs and still lack the basic facilities suggested in the national plans. For example, in India, the program is in different stages of implementation in small pockets (122 out of 626 districts). Despite its good intentions, the program failed to deliver. [sup][7],[8],[9],[10],[11] complete lack of estimates of cost and the absence of provision of budgetary support were important contributors to its failure. [sup][7] Similar situations are reported from many LMICs including South Africa where progressive legislation has been passed without an effective national program and fromNigeria where action plans were never implemented. [sup][7],[12] situation on the ground in most LMICs has not changed over the past three decades. [sup][7],[8],[11] national programs remained on paper, while some smaller initiatives, after the initial fanfare, are dysfunctional. Most experts agree that integration with primary care is nonexistent in many While programs in some LMICs have ensured wider availability to essential psychotropic medication, their failure to integrate mental health care delivery into primary care has meant limited impact on patient services. issues with regard to community care of the mentally ill in the developing world are complex and differ from those in industrialized societies. …